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Gravholt A, Pfenninger C, Grospretre S, Martin A, Lapole T. Do soleus responses to transcutaneous spinal cord stimulation show similar changes to H-reflex in response to Achilles tendon vibration? Eur J Appl Physiol 2024; 124:1821-1833. [PMID: 38252303 DOI: 10.1007/s00421-023-05406-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 12/17/2023] [Indexed: 01/23/2024]
Abstract
INTRODUCTION/PURPOSE Recently, the use of transcutaneous spinal cord stimulation (TSCS) has been proposed as a viable alternative to the H-reflex. The aim of the current study was to investigate to what extent the two modes of spinal cord excitability investigation would be similarly sensitive to the well-known vibration-induced depression. METHODS Fourteen healthy participants (8 men and 6 women; age: 26.7 ± 4.8 years) were engaged in the study. The right soleus H-reflex and TSCS responses were recorded at baseline (PRE), during right Achilles tendon vibration (VIB) and following 20 min of vibration exposure (POST-VIB). Care was taken to match H-reflex and TSCS responses amplitude at PRE and to maintain effective stimulus intensities constant throughout time points. RESULTS The statistical analysis showed a significant effect of time for the H-reflex, with VIB (13 ± 5% of maximal M-wave (Mmax) and POST-VIB (36 ± 4% of Mmax) values being lower than PRE-values (48 ± 6% of Mmax). Similarly, TSCS responses changed over time, VIB (9 ± 5% of Mmax) and POST-VIB (27 ± 5% of Mmax) values being lower than PRE-values (46 ± 6% of Mmax). Pearson correlation analyses revealed positive correlation between H-reflex and TSCS responses PRE-to-VIB changes, but not for PRE- to POST-VIB changes. CONCLUSION While the sensitivity of TSCS seems to be similar to the gold standard H-reflex to highlight the vibratory paradox, both responses showed different sensitivity to the effects of prolonged vibration, suggesting slightly different pathways may actually contribute to evoked responses of both stimulation modalities.
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Affiliation(s)
- Anders Gravholt
- Université Jean Monnet Saint-Etienne, Lyon 1, Université Savoie Mont-Blanc, Laboratoire Interuniversitaire de Biologie de la Motricité, 42023, Saint-Etienne, France
| | - Clara Pfenninger
- Université Jean Monnet Saint-Etienne, Lyon 1, Université Savoie Mont-Blanc, Laboratoire Interuniversitaire de Biologie de la Motricité, 42023, Saint-Etienne, France
| | - Sidney Grospretre
- C3S Laboratory (Culture, Sport, , Health and Society; EA 4660), Department Sport & Performance, University of Franche-Comté, Besançon, France
| | - Alain Martin
- Laboratoire INSERM U1093, Université de Bourgogne, Faculté des Sciences du Sport (UFR Staps), BP 27877, 21078, Dijon, France
| | - Thomas Lapole
- Université Jean Monnet Saint-Etienne, Lyon 1, Université Savoie Mont-Blanc, Laboratoire Interuniversitaire de Biologie de la Motricité, 42023, Saint-Etienne, France.
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Chen B, Perez MA. Altered regulation of Ia afferent input during voluntary contraction in humans with spinal cord injury. eLife 2022; 11:e80089. [PMID: 36069767 PMCID: PMC9451536 DOI: 10.7554/elife.80089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Sensory input converging on the spinal cord contributes to the control of movement. Although sensory pathways reorganize following spinal cord injury (SCI), the extent to which sensory input from Ia afferents is regulated during voluntary contraction after the injury remains largely unknown. To address this question, the soleus H-reflex and conditioning of the H-reflex by stimulating homonymous [depression of the soleus H-reflex evoked by common peroneal nerve (CPN) stimulation, D1 inhibition] and heteronymous (d), [monosynaptic Ia facilitation of the soleus H-reflex evoked by femoral nerve stimulation (FN facilitation)] nerves were tested at rest, and during tonic voluntary contraction in humans with and without chronic incomplete SCI. The soleus H-reflex size increased in both groups during voluntary contraction compared with rest, but to a lesser extent in SCI participants. Compared with rest, the D1 inhibition decreased during voluntary contraction in controls but it was still present in SCI participants. Further, the FN facilitation increased in controls but remained unchanged in SCI participants during voluntary contraction compared with rest. Changes in the D1 inhibition and FN facilitation were correlated with changes in the H-reflex during voluntary contraction, suggesting an association between outcomes. These findings provide the first demonstration that the regulation of Ia afferent input from homonymous and heteronymous nerves is altered during voluntary contraction in humans with SCI, resulting in lesser facilitatory effect on motor neurons.
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Affiliation(s)
- Bing Chen
- Shirley Ryan AbilityLab, Northwestern University, and Edward Hines Jr., VA Medical CenterChicagoUnited States
| | - Monica A Perez
- Shirley Ryan AbilityLab, Northwestern University, and Edward Hines Jr., VA Medical CenterChicagoUnited States
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Sangari S, Perez MA. Prevalence of spasticity in humans with spinal cord injury with different injury severity. J Neurophysiol 2022; 128:470-479. [PMID: 35507475 PMCID: PMC9423778 DOI: 10.1152/jn.00126.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 11/22/2022] Open
Abstract
Spasticity is one of the most common symptoms manifested following spinal cord injury (SCI). The aim of this study was to assess spasticity in individuals with subacute and chronic SCI with different injury severity, standardizing the time and assessments of spasticity. We tested 110 individuals with SCI classified by the American Spinal Injury Association Impairment Scale (AIS) as either motor complete (AIS A and B; subacute, n = 25; chronic, n = 33) or motor incomplete (AIS C and D; subacute, n = 23; chronic, n = 29) at a similar time after injury (subacute, ∼1 mo after injury during inpatient rehabilitation and chronic, ≥1 yr after injury) using clinical (modified Ashworth scale) and kinematic (pendulum test) outcomes to assess spasticity in the quadriceps femoris muscle. Using both methodologies, we found that among individuals with subacute motor complete injuries, only a minority showed spasticity, whereas the majority exhibited no spasticity. This finding stands in contrast to individuals with subacute motor incomplete injury, where both methodologies revealed that a majority exhibited spasticity, whereas a minority exhibited no spasticity. In chronic injuries, most individuals showed spasticity regardless of injury severity. Notably, when spasticity was present, its magnitude was similar across injury severity in both subacute and chronic injuries. Our results suggest that the prevalence, not the magnitude, of spasticity differs between individuals with motor complete and incomplete SCI in the subacute and chronic stages of the injury. We thus argue that considering the "presence of spasticity" might help the stratification of participants with motor complete injuries for clinical trials.NEW & NOTEWORTHY The prevalence of spasticity in humans with SCI remains poorly understood. Using kinematic and clinical outcomes, we examined spasticity in individuals with subacute and chronic injuries of different severity. We found that spasticity in the quadriceps femoris muscle was more prevalent among individuals with subacute motor incomplete than in those with motor complete injuries. However, in a different group of individuals with chronic injuries, no differences were found in the prevalence of spasticity across injury severity.
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Affiliation(s)
| | - Monica A Perez
- Shirley Ryan AbilityLab, Chicago, Illinois
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
- Edward Hines Jr., VA Hospital, Hines, Illinois
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Mesquita RNO, Taylor JL, Trajano GS, Škarabot J, Holobar A, Gonçalves BAM, Blazevich AJ. Effects of reciprocal inhibition and whole-body relaxation on persistent inward currents estimated by two different methods. J Physiol 2022; 600:2765-2787. [PMID: 35436349 PMCID: PMC9325475 DOI: 10.1113/jp282765] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/13/2022] [Indexed: 11/08/2022] Open
Abstract
Abstract Persistent inward currents (PICs) are crucial for initiation, acceleration, and maintenance of motoneuron firing. As PICs are highly sensitive to synaptic inhibition and facilitated by serotonin and noradrenaline, we hypothesised that both reciprocal inhibition (RI) induced by antagonist nerve stimulation and whole‐body relaxation (WBR) would reduce PICs in humans. To test this, we estimated PICs using the well‐established paired motor unit (MU) technique. High‐density surface electromyograms were recorded from gastrocnemius medialis during voluntary, isometric 20‐s ramp, plantarflexor contractions and decomposed into MU discharges to calculate delta frequency (ΔF). Moreover, another technique (VibStim), which evokes involuntary contractions proposed to result from PIC activation, was used. Plantarflexion torque and soleus activity were recorded during 33‐s Achilles tendon vibration and simultaneous 20‐Hz bouts of neuromuscular electrical stimulation (NMES) of triceps surae. ΔF was decreased by RI (n = 15, 5 females) and WBR (n = 15, 7 females). In VibStim, torque during vibration at the end of NMES and sustained post‐vibration torque were reduced by WBR (n = 19, 10 females), while other variables remained unchanged. All VibStim variables remained unaltered in RI (n = 20, 10 females). Analysis of multiple human MUs in this study demonstrates the ability of local, focused inhibition to attenuate the effects of PICs on motoneuron output during voluntary motor control. Moreover, it shows the potential to reduce PICs through non‐pharmacological, neuromodulatory interventions such as WBR. The absence of a consistent effect in VibStim might be explained by a floor effect resulting from low‐magnitude involuntary torque combined with the negative effects of the interventions. Key points Spinal motoneurons transmit signals to skeletal muscles to regulate their contraction. Motoneuron firing partly depends on their intrinsic properties such as the strength of persistent (long‐lasting) inward currents (PICs) that make motoneurons more responsive to excitatory input. In this study, we demonstrate that both reciprocal inhibition onto motoneurons and whole‐body relaxation reduce the contribution of PICs to human motoneuron firing. This was observed through analysis of the firing of single motor units during voluntary contractions. However, an alternative technique that involves tendon vibration and neuromuscular electrical stimulation to evoke involuntary contractions showed less effect. Thus, it remains unclear whether this alternative technique can be used to estimate PICs under all physiological conditions. These results improve our understanding of the mechanisms of PIC depression in human motoneurons. Potentially, non‐pharmacological interventions such as electrical stimulation or relaxation could attenuate unwanted PIC‐induced muscle contractions in conditions characterised by motoneuron hyperexcitability.
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Affiliation(s)
- Ricardo N O Mesquita
- Centre for Human Performance, School of Medical and Health Sciences, Edith Cowan University, Perth, Australia.,Neuroscience Research Australia, Sydney, Australia
| | - Janet L Taylor
- Centre for Human Performance, School of Medical and Health Sciences, Edith Cowan University, Perth, Australia.,Neuroscience Research Australia, Sydney, Australia
| | - Gabriel S Trajano
- School of Exercise and Nutrition Sciences and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Jakob Škarabot
- School of Sport, Exercise and Health Sciences, Loughborough University, Leicestershire, UK
| | - Aleš Holobar
- Faculty of Electrical Engineering and Computer Science, University of Maribor, Maribor, Slovenia
| | - Basílio A M Gonçalves
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Anthony J Blazevich
- Centre for Human Performance, School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
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Sandler EB, Condon K, Field-Fote EC. Efficacy of Transcutaneous Spinal Stimulation versus Whole Body Vibration for Spasticity Reduction in Persons with Spinal Cord Injury. J Clin Med 2021; 10:jcm10153267. [PMID: 34362051 PMCID: PMC8348743 DOI: 10.3390/jcm10153267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 01/07/2023] Open
Abstract
Transcutaneous spinal stimulation (TSS) and whole-body vibration (WBV) each have a robust ability to activate spinal afferents. Both forms of stimulation have been shown to influence spasticity in persons with spinal cord injury (SCI), and may be viable non-pharmacological approaches to spasticity management. In thirty-two individuals with motor-incomplete SCI, we used a randomized crossover design to compare single-session effects of TSS versus WBV on quadriceps spasticity, as measured by the pendulum test. TSS (50 Hz, 400 μs, 15 min) was delivered in supine through a cathode placed over the thoracic spine (T11-T12) and an anode over the abdomen. WBV (50 Hz; eight 45-s bouts) was delivered with the participants standing on a vibration platform. Pendulum test first swing excursion (FSE) was measured at baseline, immediately post-intervention, and 15 and 45 min post-intervention. In the whole-group analysis, there were no between- or within-group differences of TSS and WBV in the change from baseline FSE to any post-intervention timepoints. Significant correlations between baseline FSE and change in FSE were associated with TSS at all timepoints. In the subgroup analysis, participants with more pronounced spasticity showed significant decreases in spasticity immediately post-TSS and 45 min post-TSS. TSS and WBV are feasible physical therapeutic interventions for the reduction of spasticity, with persistent effects.
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Affiliation(s)
- Evan B. Sandler
- Shepherd Center, Crawford Research Institute, Atlanta, GA 30309, USA; (E.B.S.); (K.C.)
- Program in Biological Sciences, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Kyle Condon
- Shepherd Center, Crawford Research Institute, Atlanta, GA 30309, USA; (E.B.S.); (K.C.)
| | - Edelle C. Field-Fote
- Shepherd Center, Crawford Research Institute, Atlanta, GA 30309, USA; (E.B.S.); (K.C.)
- Program in Biological Sciences, Georgia Institute of Technology, Atlanta, GA 30332, USA
- Division of Physical Therapy, Emory University School of Medicine, Atlanta, GA 30322, USA
- Correspondence: ; Tel.: +1-404-603-4274
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Mildren RL, Peters RM, Carpenter MG, Blouin JS, Inglis JT. Soleus responses to Achilles tendon stimuli are suppressed by heel and enhanced by metatarsal cutaneous stimuli during standing. J Physiol 2021; 599:3611-3625. [PMID: 34047370 DOI: 10.1113/jp281744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/12/2021] [Indexed: 02/05/2023] Open
Abstract
KEY POINTS We examined the influence of cutaneous feedback from the heel and metatarsal regions of the foot sole on the soleus stretch reflex pathway during standing. We found that heel electrical stimuli suppressed and metatarsal stimuli enhanced the soleus vibration response. Follow-up experiments indicated that the interaction between foot sole cutaneous feedback and the soleus vibration response was likely not mediated by presynaptic inhibition and was contingent upon a modulation at the ⍺-motoneuron pool level. The spatially organized interaction between cutaneous feedback from the foot sole and the soleus vibration response provides information about how somatosensory information is combined to appropriately respond to perturbations during standing. ABSTRACT Cutaneous feedback from the foot sole provides balance-relevant information and has the potential to interact with spinal reflex pathways. In this study, we examined how cutaneous feedback from the foot sole (heel and metatarsals) influenced the soleus response to proprioceptive stimuli during standing. We delivered noisy vibration (10-115 Hz) to the right Achilles tendon while we intermittently applied electrical pulse trains (five 1-ms pulses at 200 Hz, every 0.8-1.0 s) to the skin under either the heel or the metatarsals of the ipsilateral foot sole. We analysed time-dependent (referenced to cutaneous stimuli) coherence and cross-correlations between the vibration acceleration and rectified soleus EMG. Vibration-EMG coherence was observed across a bandwidth of ∼10-80 Hz, and coherence was suppressed by heel but enhanced by metatarsal cutaneous stimuli. Cross-correlations showed soleus EMG was correlated with the vibration (∼40 ms lag) and cross-correlations were also suppressed by heel (from 104-155 ms) but enhanced by metatarsal (from 76-128 ms) stimuli. To examine the neural mechanisms mediating this reflex interaction, we conducted two further experiments to probe potential contributions from (1) presynaptic inhibition, and (2) modulations at the ⍺- and γ-motoneuron pools. Results suggest the cutaneous interactions with the stretch reflex pathway required a modulation at the ⍺-motoneuron pool and were likely not mediated by presynaptic inhibition. These findings demonstrate that foot sole cutaneous information functionally tunes the stretch reflex pathway during the control of upright posture and balance.
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Affiliation(s)
- Robyn L Mildren
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ryan M Peters
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Mark G Carpenter
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada.,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada
| | - Jean-Sébastien Blouin
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada.,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada.,Institute for Computing, Information and Cognitive Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Timothy Inglis
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada.,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada
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Barss TS, Collins DF, Miller D, Pujari AN. Indirect Vibration of the Upper Limbs Alters Transmission Along Spinal but Not Corticospinal Pathways. Front Hum Neurosci 2021; 15:617669. [PMID: 34079443 PMCID: PMC8165249 DOI: 10.3389/fnhum.2021.617669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/19/2021] [Indexed: 01/15/2023] Open
Abstract
The use of upper limb vibration (ULV) during exercise and rehabilitation continues to gain popularity as a modality to improve function and performance. Currently, a lack of knowledge of the pathways being altered during ULV limits its effective implementation. Therefore, the aim of this study was to investigate whether indirect ULV modulates transmission along spinal and corticospinal pathways that control the human forearm. All measures were assessed under CONTROL (no vibration) and ULV (30 Hz; 0.4 mm displacement) conditions while participants maintained a small contraction of the right flexor carpi radialis (FCR) muscle. To assess spinal pathways, Hoffmann reflexes (H-reflexes) elicited by stimulation of the median nerve were recorded from FCR with motor response (M-wave) amplitudes matched between conditions. An H-reflex conditioning paradigm was also used to assess changes in presynaptic inhibition by stimulating the superficial radial (SR) nerve (5 pulses at 300Hz) 37 ms prior to median nerve stimulation. Cutaneous reflexes in FCR elicited by stimulation of the SR nerve at the wrist were also recorded. To assess corticospinal pathways, motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation of the contralateral motor cortex were recorded from the right FCR and biceps brachii (BB). ULV significantly reduced H-reflex amplitude by 15.7% for both conditioned and unconditioned reflexes (24.0 ± 15.7 vs. 18.4 ± 11.2% M max ; p < 0.05). Middle latency cutaneous reflexes were also significantly reduced by 20.0% from CONTROL (-1.50 ± 2.1% Mmax) to ULV (-1.73 ± 2.2% Mmax; p < 0.05). There was no significant effect of ULV on MEP amplitude (p > 0.05). Therefore, ULV inhibits cutaneous and H-reflex transmission without influencing corticospinal excitability of the forearm flexors suggesting increased presynaptic inhibition of afferent transmission as a likely mechanism. A general increase in inhibition of spinal pathways with ULV may have important implications for improving rehabilitation for individuals with spasticity (SCI, stroke, MS, etc.).
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Affiliation(s)
- Trevor S. Barss
- Human Neurophysiology Laboratory, Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - David F. Collins
- Human Neurophysiology Laboratory, Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Dylan Miller
- Human Neurophysiology Laboratory, Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Amit N. Pujari
- School of Engineering and Computer Science, University of Hertfordshire, Hatfield, United Kingdom
- Biomedical Engineering Laboratory, School of Engineering, University of Aberdeen, Aberdeen, United Kingdom
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Kumru H, Albu S, Oguz S, Murillo N, Lucente G, Valls-Sole J. Effects of different vibration frequencies on spinal cord reflex circuits and thermoalgesic perception. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2021; 21:533-541. [PMID: 34854393 PMCID: PMC8672409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We studied the effect of different vibration frequencies on spinal cord excitability and heat pain perception. We hypothesized that the effects of vibration on spinal cord reflexes, and, also those on heat pain perception, depend on vibration frequency. METHODS In 9 healthy subjects, we applied vibration over the tibialis anterior muscle at three different frequencies (50, 150, or 250 Hz) on spinal cord reflex excitably, tested with the H reflex and the T wave in the soleus muscle, as well as on sensory and pain perception, tested by measuring warm perception (WT) and heat pain perception thresholds, (HPT) in sites rostral and caudal to vibration. Exams were carried out before, during, and after vibration. RESULTS The amplitude of the H reflex and T wave significantly decreased during vibration in comparison to baseline. Low frequencies (50 and 150Hz) induced greater reflex suppression than high frequency (250Hz). No significant changes were observed on WT and HPT. CONCLUSIONS The effects of vibratory stimulation can be summarized as frequency-related suppression of the spinal cord excitability without an effect on warm and heat pain perception. The present results may help to design vibration-related interventions intended to diminish spinal cord reflex excitability in spastic patients.
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Affiliation(s)
- Hatice Kumru
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Barcelona, Spain,Univ Autonoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain,Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain,Corresponding author: Hatice Kumru, MD, PhD, Hospital de Neurorehabilitació Institut Guttmann, Camí Can Ruti s/n. Barcelona, 08916 Barcelona, Spain E-mail:
| | - Sergiu Albu
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Barcelona, Spain,Univ Autonoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain,Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Semra Oguz
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Barcelona, Spain,Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Narda Murillo
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Barcelona, Spain,Univ Autonoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain,Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Giuseppe Lucente
- Univ Autonoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain,Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain,Neuromuscular and Neuropediatric group, Neuroscience department, Hospital Universitario Germans Trias I Pujol, Badalona, Spain
| | - Josep Valls-Sole
- IDIBAPS (Institut d’Investigació Biomèdica August Pi i Sunyer), Barcelona, Spain
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